Top five low-value actions ID'd in emergency medicine

(HealthDay)—The top five tests, treatments, and/or disposition decisions that are of little value in emergency medicine have been identified, according to research published online Feb. 17 in JAMA: Internal Medicine.

Jeremiah D. Schuur, M.D., M.H.S., from the Brigham and Women's Hospital in Boston, and colleagues assembled a technical expert panel (TEP) and conducted a modified Delphi process to identify a top-five list of tests, treatment, and disposition decisions that are of little value and are actionable by clinicians. A four-stage process was used to create the list, which included surveying 283 emergency medicine clinicians from six emergency departments.

The researchers identified 64 low-value items, which were narrowed down to 17 items that all showed a significant positive correlation between benefit and actionability. One item received unanimous TEP support and four received majority support. According to the top-five list: (1) computed tomography (CT) of the cervical spine should not be ordered after trauma for patients who are not considered high-risk and do not meet the National Emergency X-ray Utilization Study low-risk criteria or the Canadian C-Spine Rule; (2) for suspected pulmonary embolism, CT for diagnosis should not be ordered without first determining the patient's pulmonary embolism risk (pretest probability and D-dimer tests if low probability); (3) magnetic resonance imaging of the lumbar spine should not be ordered for patients with lower back pain who do not have high-risk features; (4) head CT should not be ordered for patients with mild traumatic head injury who do not meet New Orleans Criteria or Canadian CT Head Rule; and (5) anticoagulation studies should not be ordered for patients without hemorrhage or suspected clotting disorder.

"Developing and addressing a top-five list is a first step to addressing the critical issue of the value of emergency care," the authors write.

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